BILL ANALYSIS                                                                                                                                                                                                    Ó




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          |SENATE RULES COMMITTEE            |                        SB 484|
          |Office of Senate Floor Analyses   |                              |
          |(916) 651-1520    Fax: (916)      |                              |
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                                UNFINISHED BUSINESS 


          Bill No:  SB 484
          Author:   Beall (D), et al.
          Amended:  9/3/15  
          Vote:     21  

           SENATE HUMAN SERVICES COMMITTEE:  5-0, 4/21/15
           AYES:  McGuire, Berryhill, Hancock, Liu, Nguyen

           SENATE HEALTH COMMITTEE:  9-0, 4/29/15
           AYES:  Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen,  
            Pan, Roth, Wolk

           SENATE APPROPRIATIONS COMMITTEE:  7-0, 5/28/15
           AYES:  Lara, Bates, Beall, Hill, Leyva, Mendoza, Nielsen

           SENATE FLOOR:  40-0, 6/3/15
           AYES:  Allen, Anderson, Bates, Beall, Berryhill, Block,  
            Cannella, De León, Fuller, Gaines, Galgiani, Glazer, Hall,  
            Hancock, Hernandez, Hertzberg, Hill, Hueso, Huff, Jackson,  
            Lara, Leno, Leyva, Liu, McGuire, Mendoza, Mitchell, Monning,  
            Moorlach, Morrell, Nguyen, Nielsen, Pan, Pavley, Roth, Runner,  
            Stone, Vidak, Wieckowski, Wolk

           ASSEMBLY FLOOR:  79-0, 9/8/15 - See last page for vote
           
           SUBJECT:   Juveniles


          SOURCE:    National Center for Youth Law


          DIGEST:  The bill requires California Department of Social  
          Services (CDSS)  to establish a methodology for identifying  
          group homes that have levels of psychotropic dug utilization  
          warranting additional review, and to inspect identified  








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          facilities at least once a year, as specified. Additionally,  
          this bill permits CDSS to share information and observations  
          with the facility and to require the facility to submit a plan  
          within 30 days to address identified risks, as specified.  




          Assembly Amendments add licensing provisions stating that  
          psychotropic medications shall only be used in accordance with  
          the written directions of the prescribing physician and as  
          authorized by the juvenile court. Amendments further add  
          licensing provisions requiring facilities to maintain specified  
          information in the child's records regarding psychotropic  
          medication. Additionally, amendments narrow the scope of the  
          information and measurements required to be considered in  
          establishing the methodology for identifying group homes and  
          strikes specified components to be included in a corrective plan  
          submitted by a facility. Further, amendments strike specific  
          components to be determined by CDSS in monitoring of the  
          facilities implementation of the plan.


          ANALYSIS:   


          Existing law:


          1)Establishes the Community Care Facilities Act, which provides  
            for the licensure and regulation of community care facilities,  
            including group homes, by CDSS, and requires that licensed  
            facilities be subject to unannounced inspections under  
            specified circumstances. (HSC 1500 et seq, and 1534)


          2)Requires CDSS to establish a rate classification level (RCL)  
            structure for group homes with a corresponding rate structure  
            according to the level of care and services that will be  
            provided, as specified. (WIC 11462)










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          3)Permits a group home to be classified as an RCL 13 or 14 if  
            the program only accepts children with special treatment needs  
            and meets other requirements. Additionally, requires the  
            California Department of Health Care Services (DHCS) to  
            annually certify group homes seeking classification as RCL 13  
            or 14 and permits such facilities to accept minor dependents  
            who are seriously or emotionally disturbed if certain  
            conditions are met. (WIC 11469, WIC 4096.5 and HSC 1502.4)


          4)Requires CDSS to publish and make available to interested  
            persons a list or lists covering all licensed community care  
            facilities, other than foster family homes and certified  
            family homes, to include specified information regarding group  
            homes, transitional housing placement providers, community  
            treatment facilities or runaway and homeless youth shelters  
            including complaints, citations, fines and the number of law  
            enforcement contacts made by group homes. (HSC 1536)


          This bill:


            1)  Requires CDSS to compile, to the extent feasible and based  
              on information provided by the California Department of  
              Health Care Services (DHCS), specified child welfare  
              psychotropic medication measures developed by CDSS and  
              specified Healthcare Effectiveness Data and Information Set  
              (HEDIS) measures related to psychotropic medication,  
              pertaining to each group home, in order to review and  
              evaluate the use of psychotropic medication in group homes.   
              


            2)  Requires CDSS to establish a methodology for identifying  
              group homes that have levels of psychotropic dug utilization  
              warranting additional review, in consultation with DHCS. 


            3)  Requires CDSS to inspect a facility identified as  
              appearing to have levels of psychotropic medication  
              utilization warranting additional review at least once a  








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              year, and requires the inspection to include, but not be  
              limited to, a review of the facilities plan of operation,  
              child-to-staff rations, staff qualifications and training,  
              implementation of children's needs and services plan,  
              confidential interviews of residents, and availability of  
              psychosocial and other alternative treatment to the use of  
              psychotropic medication.


            4)  Permits CDSS to include confidential discussions with  
              former residents, and confidential discussions with  
              physicians prescribing medications to residents. 


            5)  Permits CDSS to do either or both of the following after  
              an inspection:


               a)     Share relevant information and observations with  
                 county placing agencies, social workers and probation  
                 officers, the court, dependency counsel, or the Medical  
                 Board of California. 


               b)     Share relevant information and observations with the  
                 facility and require the facility to submit a plan,  
                 within 30 days, to address any identified risks within  
                 the control of the facility. Requires CDSS to approve and  
                 monitor implementation of the plan.


            6)  Provides that psychotropic medications shall only be used  
              in accordance with the written directions of the prescribing  
              physician and as authorized by the juvenile court. 


            7)  Requires facilities to maintain specified information in  
              the child's records regarding psychotropic medication  
              including a copy of any court order authorizing psychotropic  
              medications and a separate log for each medication, as  
              specified.









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            8)  Permits CDSS to implement this bill through all-county  
              letters or similar instructions until regulations are filed  
              and requires emergency regulations to be adopted on or  
              before January 1, 2017 and final regulations to be adopted  
              on or before January 1, 2018.


            9)  Requires CDSS to monitor the facility's implementation of  
              the plan to determine whether the facility has reduced the  
              rate that psychotropic medications are administered, and the  
              percentage decrease; whether and to what extent alternative  
              less invasive treatments are being provided to residents,  
              and the percentage increase; whether and to what extent 


            10) Requires CDSS and DHCS in consultation with specified  
              stakeholders to develop additional performance standards and  
              outcome measures that require group homes to implement  
              programs and services to reduce the utilization of  
              psychotropic medications in group homes, including  
              behavioral management programs, emergency intervention  
              plans, and conflict resolution processes.


            11) Requires CDSS to post on its internet website a statewide  
              summary of information gathered pursuant to this bill and  
              requires such information be de-identified and aggregate,  
              and does not violate the confidentiality of a child's  
              identity and records.


          Background


          Group Homes. Group homes are 24-hour residential facilities  
          licensed by CDSS to provide board and care to foster youth from  
          both the dependency and delinquency jurisdictions. Group home  
          facilities are organized under a system of rate classification  
          levels (RCLs) ranging from 1-14 that are based on levels of  
          professional training and adult-to-child ratios. In practice,  
          the majority of group homes are at or above RCL 10 with nearly  








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          50 percent of group homes at RCL 12. There is wide variation in  
          group home size from as few as six children to more than 100. 


          Group Home Program Statement. Group homes are required to  
          establish a "group home program statement" that includes a  
          training plan that is appropriate for the client population and  
          the training needs and skill level of child care staff. Through  
          regulation, existing law provides that newly hired staff  
          complete at least 24 hours of training within 90 days of being  
          hired, and 40 hours within 12 months, as specified, with all  
          existing staff receiving 20 hours annually. Regulations provide  
          for the minimum topics that must be included (e.g. discipline  
          policies and procedures, behavior problems / psychological  
          disorders, and mental health / behavioral interventions). Social  
          work staff is required to establish a "needs and services plan"  
          for each child that identifies the specific needs of an  
          individual child, and delineates those services necessary in  
          order to meet the child's identified needs. 


          Group homes are required to submit to the department an  
          emergency intervention plan, identifying how the facility will  
          use emergency interventions to address aggressive or assaultive  
          behavior of residents. The plan is required to be designed by  
          the licensee and a qualified behavior management consultant and  
          must be appropriate for the client population served by the  
          group home, and for the staff qualifications and staff emergency  
          intervention training.


          Psychotropic Medication Use in Children. Concern over the use of  
          psychotropic medications among children has been well-documented  
          in research journals and the mainstream media for more than a  
          decade. The category of psychotropic medication is fairly broad,  
          intending to treat symptoms of conditions ranging from ADHD to  
          childhood schizophrenia. Some of the drugs used to treat these  
          conditions are FDA-approved, including stimulants like Ritalin  
          for ADHD, however only about 31 percent of psychotropic  
          medications have been approved by the U.S. Food and Drug  
          Administration (FDA) for use in children or adolescents. It is  
          estimated that more than 75 percent of the prescriptions written  








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          for psychiatric illness in this population are "off label" in  
          usage, meaning they have not been approved by the FDA for the  
          prescribed use, though the practice is legal and common across  
          all manner of pharmaceuticals.


          Anti-psychotic medications, used to treat more severe mental  
          health conditions, include powerful brand-name drugs such as  
          Haldol, Risperdal, Abilify, Seroquel and Zyprexa. They have very  
          limited approval by the FDA for pediatric use beyond rare and  
          severe conduct problems that are resistant to other forms of  
          treatment, such as Tourette's syndrome, behavioral symptoms  
          associated with autistic disorder, childhood schizophrenia, and  
          bipolar disorder. However, the off-label use of these  
          anti-psychotics among children is high, particularly among  
          foster children. According to a study published in 2011,  
          children who took antipsychotic medications were likely to  
          suffer ill health effects including "cardiometabolic and  
          endocrine side-effects" as well as significant weight gain. The  
          authors recommended that collaboration between child and  
          adolescent psychiatrists, general practitioners and  
          pediatricians is essential to "reduce the likelihood of  
          premature cardiovascular morbidity and mortality." 


          Compounding the potential for unintended side effects is the use  
          of combinations of psychotropic medications, which foster youth  
          are particularly likely to be prescribed, despite limited  
          evidence of clinical efficacy. 


          Prescribing rates in California. A recent series of stories  
          published in the San Jose Mercury News detailed significant  
          challenges in accessing pharmacy benefits claims data held by  
          the DHCS, and demonstrated that prescribing rates were far  
          higher than had been anticipated by child welfare system  
          experts. Specifically, the data revealed that nearly 1 in 4  
          youth, and 56 percent of all youth residing in group homes were  
          prescribed at least one psychotropic medication. Furthermore,  
          for those youth prescribed psychotropic medications, nearly 60  
          percent were prescribed an anti-psychotic - the powerful drug  
          class most associated with debilitating side effects, and 36  








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          percent were prescribed multiple medications, also referred to  
          as "polypharmacy."


          Increases observed in California mirror those across the nation  
          - children in foster care represent only three percent of  
          children covered by Medicaid, yet, a study of pharmacy claims in  
          16 states showed that foster children enrolled in Medicaid were  
          prescribed antipsychotic medications at nearly nine times the  
          rate of other children receiving Medicaid.


          FISCAL EFFECT:   Appropriation:    No          Fiscal  
          Com.:YesLocal:   Yes


          The Assembly Appropriations Committee states this bill may incur  
          ongoing costs in the range of $300,000 to $600,000 (GF) per year  
          to CDSS to conduct annual site visits at group homes identified  
          as having disproportionately high and inappropriate levels of  
          psychotropic medication use by foster youth. Additionally, the  
          analysis estimates one-time costs of approximately $250,000 (GF)  
          to CDSS to compile information on group homes, consult with  
          stakeholders, and develop a methodology to identify group homes  
          for additional scrutiny and ongoing costs of $130,000 ($65,000  
          GF) to DHCS to identify, evaluate and collate claims data  
          packages to be used for the purposes of this bill.


          SUPPORT:   (Verified 9/8/15)


          Advokids
          Alameda County Foster Youth Alliance
          All Saints Foster Care Project
          California Court Appointed Special Advocates
          California Department of Justice
          California Youth Connection
          Children's Advocacy Institute
          Children's Defense Fund - California
          Children's Law Center of California
          Children's Partnership








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          Consumer Watchdog
          Dependency Legal Group of San Diego
          East Bay Children's Law Offices
          East Bay Community Law Center
          First Focus Campaign for Children
          First Place for Youth
          Humboldt County Transition Age You Collaboration
          Legal Advocates for Children and Youth
          Legal Services for Prisoners with Children
          Mockingbird Society
          National Association of Social Workers
          National Center for Youth Law
          Peers Envisioning and Engaging in Recovery Services
          Public Counsel's Children's Rights Project
          Santa Clara Board of Supervisors
          Youth Law Center
          10 individuals 


          OPPOSITION:   (Verified9/8/15)


          None received

           ASSEMBLY FLOOR:  79-0, 9/08/15
           AYES: Achadjian, Alejo, Travis Allen, Baker, Bigelow, Bloom,  
            Bonilla, Bonta, Brough, Brown, Burke, Calderon, Campos, Chang,  
            Chau, Chiu, Chu, Cooley, Cooper, Dababneh, Dahle, Daly, Dodd,  
            Eggman, Frazier, Beth Gaines, Gallagher, Cristina Garcia,  
            Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez, Gordon, Gray,  
            Grove, Hadley, Harper, Roger Hernández, Holden, Irwin, Jones,  
            Jones-Sawyer, Kim, Lackey, Levine, Linder, Lopez, Low,  
            Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin,  
            Nazarian, Obernolte, O'Donnell, Olsen, Patterson, Perea,  
            Quirk, Rendon, Ridley-Thomas, Rodriguez, Salas, Santiago,  
            Steinorth, Mark Stone, Thurmond, Ting, Wagner, Waldron, Weber,  
            Wilk, Williams, Wood, Atkins
           NO VOTE RECORDED: Chávez


          Prepared by:Sara Rogers / HUMAN S. / (916) 651-1524
          9/8/15 19:24:28








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